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There are no adequately powered randomized trials comparing different fasting and postmeal glycemic targets in diabetes in pregnancy. The 2021 Standards of Care is now live online in Diabetes Care. Planning pregnancy is critical in women with preexisting diabetes due to the need for preconception glycemic control to prevent congenital malformations and reduce the risk of other complications. Checklist for preconception care for women with diabetes (17,19). Members of the ADA Professional Practice Committee, a . Because GDM is associated with an increased lifetime maternal risk for diabetes estimated at 5060% (119,120), women should also be tested every 13 years thereafter if the 412 weeks postpartum 75-g OGTT is normal. Classification and Diagnosis of Diabetes:Standards of Medical Care in Diabetes2021. This needs to be individualized for the patient, so discuss the amount needed with your diabetes team. Periodontal disease is commonly seen in people with diabetes, 22-24 and is considered a complication of diabetes. In the Metformin in Gestational Diabetes: The Offspring Follow-Up (MiG TOFU) study's analyses of 7- to 9-year-old offspring, the 9-year-old offspring exposed to metformin in the Auckland cohort for the treatment of GDM were heavier and had a higher waist-to-height ratio and waist circumference than those exposed to insulin (72). In two RCTs of metformin use in pregnancy for polycystic ovary syndrome, follow-up of 4-year-old offspring demonstrated higher BMI and increased obesity in the offspring exposed to metformin (81,82). A follow-up study at 510 years showed that the offspring had higher BMI, weight-to-height ratios, waist circumferences, and a borderline increase in fat mass (82,83). B. Gestational diabetes screening is recommended at both 12-16 weeks and 24-48 weeks gestation with a 2h 75g-OGTT and 0, 1, and 2h glucose measures. Given that early pregnancy is a time of enhanced insulin sensitivity and lower glucose levels, many women with type 1 diabetes will have lower insulin requirements and an increased risk for hypoglycemia (30). A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. The 2015 study (104) excluded pregnancies complicated by preexisting diabetes and only 6% had GDM at enrollment. E. Because GDM often represents previously undiagnosed prediabetes, type 2 diabetes, maturity-onset diabetes of the young, or even developing type 1 diabetes, women with GDM should be tested for persistent diabetes or prediabetes at 412 weeks postpartum with a 75-g OGTT using nonpregnancy criteria as outlined in Section 2 Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc21-S002). American Diabetes Association Releases 2023 Standards of Care in Management of diabetes in pregnancy: Standards of Medical Care in Diabetes2021. However, metformin readily crosses the placenta, resulting in umbilical cord blood levels of metformin as high or higher than simultaneous maternal levels (78,79). Simple carbohydrates will result in higher postmeal excursions. C. The physiology of pregnancy necessitates frequent titration of insulin to match changing requirements and underscores the importance of daily and frequent self-monitoring of blood glucose. Some women with preexisting diabetes should also test blood glucose preprandially. Those with elevated blood pressure measurements should have their measurements repeated on a . The importance of preconception care for all women is highlighted by the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 762, Prepregnancy Counseling (17). B, 15.10 When used in addition to blood glucose monitoring targeting traditional pre- and postprandial targets, real-time continuous glucose monitoring can reduce macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADAs clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Special attention should be paid to the review of the medication list for potentially harmful drugs (i.e., ACE inhibitors [20,21], angiotensin receptor blockers [20], and statins [22,23]). E. Diabetes in pregnancy is associated with an increased risk of preeclampsia (95). B, 15.18 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. Insulin pumps that allow for the achievement of pregnancy fasting and postprandial glycemic targets may reduce hypoglycemia and allow for more aggressive prandial dosing to achieve targets. There are opportunities to educate all women and adolescents of reproductive age with diabetes about the risks of unplanned pregnancies and about improved maternal and fetal outcomes with pregnancy planning (8). B, 14.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. The Standards of Medical Care in Diabetes2021 provides the latest in comprehensive, evidence-based recommendations for the diagnosis and treatment of children and adults with type 1, type 2, or gestational diabetes; strategies for the prevention or delay of type 2 diabetes; and therapeutic approaches that can reduce complications, mitigate Adjusting for BMI attenuated this association moderately, but not completely. In these women, lifestyle intervention and metformin reduced progression to diabetes by 35% and 40%, respectively, over 10 years compared with placebo (124). The pharmacologic basis for better clinical practice, Pharmacokinetics, efficacy and safety of glyburide for treatment of gestational diabetes mellitus, Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis, Comparative impact of pharmacological treatments for gestational diabetes on neonatal anthropometry independent of maternal glycaemic control: a systematic review and meta-analysis, Groupe de Recherche en Obsttrique et Gyncologie (GROG), Effect of glyburide vs subcutaneous insulin on perinatal complications among women with gestational diabetes: a randomized clinical trial, Metformin compared with glyburide for the management of gestational diabetes, Glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus: a randomized controlled study, Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials, Placental passage of metformin in women with polycystic ovary syndrome, Population pharmacokinetics of metformin in late pregnancy, Metformin in gestational diabetes: the offspring follow-up (MiG TOFU): body composition and metabolic outcomes at 7-9 years of age, Metformin use in PCOS pregnancies increases the risk of offspring overweight at 4 years of age: follow-up of two RCTs, Neonatal, infant, and childhood growth following metformin versus insulin treatment for gestational diabetes: a systematic review and meta-analysis, Intrauterine metformin exposure and offspring cardiometabolic risk factors (PedMet study): a 5-10 year follow-up of the PregMet randomised controlled trial, Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, controlled multicenter study, Cooperative Multicenter Reproductive Medicine Network, Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome, Prospective parallel randomized, double-blind, double-dummy controlled clinical trial comparing clomiphene citrate and metformin as the first-line treatment for ovulation induction in nonobese anovulatory women with polycystic ovary syndrome, Metformin administration versus laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: a prospective parallel randomized double-blind placebo-controlled trial, A cautionary response to SMFM statement: pharmacological treatment of gestational diabetes, Metformin for gestational diabetes mellitus: progeny, perspective, and a personalized approach, Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes, Insulin glargine safety in pregnancy: a transplacental transfer study, Transfer of insulin lispro across the human placenta, Transfer of insulin lispro across the human placenta: in vitro perfusion studies, Evaluation of insulin antibodies and placental transfer of insulin aspart in pregnant women with type 1 diabetes mellitus, Insulin detemir does not cross the human placenta, Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes, A randomized trial comparing perinatal outcomes using insulin detemir or neutral protamine Hagedorn in type 1 diabetes, Fetal and perinatal outcomes in type 1 diabetes pregnancy: a randomized study comparing insulin aspart with human insulin in 322 subjects, Insulin lispro therapy in pregnancies complicated by type 1 diabetes mellitus, Safety of insulin glargine use in pregnancy: a systematic review and meta-analysis, Continuous subcutaneous insulin infusion versus intensive conventional insulin therapy in type I and type II diabetic pregnancy, Fetal growth in women managed with insulin pump therapy compared to conventional insulin, Predictive low-glucose suspend reduces hypoglycemia in adults, adolescents, and children with type 1 diabetes in an at-home randomized crossover study: results of the PROLOG trial, Metformin in women with type 2 diabetes in pregnancy (MiTy): a multicentre, international, randomised, placebo-controlled trial, Poor pregnancy outcome in women with type 2 diabetes, Differing causes of pregnancy loss in type 1 and type 2 diabetes, Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies, Low-dose aspirin for the prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force, Rockville, MD, Agency for Healthcare Research and Quality, 2014. Diabetes Care, a monthly journal of the American Diabetes Association (ADA), is the highest-ranked, peer-reviewed journal in the field of diabetes treatment and prevention. A, 15.16 Telehealth visits for pregnant women with gestational diabetes mellitus improve outcomes compared with standard in-person care. 14.18 Women with type 1 or type 2 diabetes should be prescribed low-dose aspirin 100150 mg/day starting at 12 to 16 weeks of gestation to lower the risk of preeclampsia. Treatment aims to keep your blood glucose (blood sugar) levels normal. B, 14.11 Continuous glucose monitoring metrics may be used as an adjunct but should not be used as a substitute for self-monitoring of blood glucose to achieve optimal pre- and postprandial glycemic targets. Diabetes-specific testing should include A1C, creatinine, and urinary albumin-to-creatinine ratio. This applies to women in the immediate postpartum period. Gestational diabetes mellitus: Glucose management and - UpToDate Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. Hypoglycemia (Low Blood Glucose) | ADA - American Diabetes Association E, 15.28 Postpartum care should include psychosocial assessment and support for self-care. It is required that all programs that are accredited/recognized by ADCES and ADA meet these guidelines in order to bill for Medicare. More studies are needed to assess the long-term effects of prenatal aspirin exposure on offspring (113). In practice, it may be challenging for women with type 1 diabetes to achieve these targets without hypoglycemia, particularly women with a history of recurrent hypoglycemia or hypoglycemia unawareness. The American Diabetes Association (ADA) suggests the following options: 4 ounces (1/2 cup) of juice or regular soda, 8 ounces (1 cup) of skim milk, or 5 to 6 hard candies (eg, Life-Savers); glucose tablets can also be used (check package for grams per tablet as content varies). Although observational studies are confounded by the association between elevated periconceptional A1C and other poor self-care behavior, the quantity and consistency of data are convincing and support the recommendation to optimize glycemia prior to conception, given that organogenesis occurs primarily at 58 weeks of gestation, with an A1C <6.5% (48 mmol/mol) being associated with the lowest risk of congenital anomalies, preeclampsia, and preterm birth (37). The A1C target in a given patient should be achieved without hypoglycemia, which, in addition to the usual adverse sequelae, may increase the risk of low birth weight (45). Box 7023 Merrifield, VA 22116-7023. 190: Gestational Diabetes Mellitus. These values represent optimal control if they can be achieved safely. The necessary rapid implementation of euglycemia in the setting of retinopathy is associated with worsening of retinopathy (23). However, there is insufficient data regarding the benefits of aspirin in women with preexisting diabetes (98). Appropriate use of over-the-counter medications and supplements, Evaluation of diabetes and its comorbidities and complications, including: DKA/severe hyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care; comorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and thyroid dysfunction; complications such as macrovascular disease, nephropathy, neuropathy (including autonomic bowel and bladder dysfunction), and retinopathy, Evaluation of obstetric/gynecologic history, including history of: cesarean section, congenital malformations or fetal loss, current methods of contraception, hypertensive disorders of pregnancy, postpartum hemorrhage, preterm delivery, previous macrosomia, Rh incompatibility, and thrombotic events (DVT/PE), Review of current medications and appropriateness during pregnancy, Diabetes complications and comorbidities, including: comprehensive foot exam; comprehensive ophthalmologic exam; ECG in women starting at age 35 years who have cardiac signs/symptoms or risk factors and, if abnormal, further evaluation; lipid panel; serum creatinine; TSH; and urine protein-to-creatinine ratio. All women of childbearing age with diabetes should be informed about the importance of achieving and maintaining as near euglycemia as safely possible prior to conception and throughout pregnancy. C. The physiology of pregnancy necessitates frequent titration of insulin to match changing requirements and underscores the importance of daily and frequent blood glucose monitoring. 2451 Crystal Drive, Suite 900 Arlington, VA 22202. Retinopathy is a special concern in pregnancy. It can include special meal plans and regular physical activity. P.O. Oral agents may be an alternative in these women after a discussion of the known risks and the need for more long-term safety data in offspring. Due to the complexity of insulin management in pregnancy, referral to a specialized center offering team-based care (with team members including maternal-fetal medicine specialist, endocrinologist or other provider experienced in managing pregnancy in women with preexisting diabetes, dietitian, nurse, and social worker, as needed) is recommended if this resource is available. 201: Pregestational diabetes mellitus, Diabetes and Reproductive Health for Girls, American College of Obstetricians and Gynecologists Committee on Gynecologic Practice, American Society for Reproductive Medicine, ACOG Committee Opinion No. American Diabetes Association "Standards of Medical Care-2020 for E A dosage of 162 mg/day may be acceptable; currently in the U.S., low-dose aspirin is available in 81-mg tablets. Gestational Diabetes | ACOG The OGTT is recommended over A1C at 412 weeks postpartum because A1C may be persistently impacted (lowered) by the increased red blood cell turnover related to pregnancy, by blood loss at delivery, or by the preceding 3-month glucose profile. Diabetes confers significantly greater maternal and fetal risk largely related to the degree of hyperglycemia but also related to chronic complications and comorbidities of diabetes. Available from, Aspirin for the prevention of preterm and term preeclampsia: systematic review and metaanalysis, Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia, Low-dose aspirin for the prevention of preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): a randomised, double-blind, placebo-controlled trial, A Cost-benefit analysis of low-dose aspirin prophylaxis for the prevention of preeclampsia in the United States, Aspirin for the prevention of preeclampsia and potential consequences for fetal brain development, International Society for the Study of Hypertension in Pregnancy (ISSHP), Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice, ACOG Practice Bulletin No. However, there is no consensus on the structure of multidisciplinary team care for diabetes and pregnancy, and there is a lack of evidence on the impact on outcomes of various methods of health care delivery (28). Low-dose aspirin >100 mg is required (109111). These recommendations were developed by a panel of experts who built upon prior Standards be reviewing the latest and most significant scientific research. Several studies have shown improved diabetes and pregnancy outcomes when care has been delivered from preconception through pregnancy by a multidisciplinary group focused on improved glycemic control (2427). Lower limits do not apply to diet-controlled type 2 diabetes. Observational studies in preexisting diabetes and pregnancy show the lowest rates of adverse fetal outcomes in association with A1C <66.5% (4248 mmol/mol) early in gestation (46,38). A, 14.23 Screen women with a recent history of gestational diabetes mellitus at 412 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. A referral for a comprehensive eye exam is recommended. Target range 63140 mg/dL (3.57.8 mmol/L): TIR, goal >70%, Time below range (<63 mg/dL [3.5 mmol/L]), goal <4%, Time below range (<54 mg/dL [3.0 mmol/L]), goal <1%, Time above range (>140 mg/dL [7.8 mmol/L]), goal <25%, 15.13 Lifestyle behavior change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. In women with normal pancreatic function, insulin production is sufficient to meet the challenge of this physiological insulin resistance and to maintain normal glucose levels. Diabetes confers significantly greater maternal and fetal risk largely related to the degree of hyperglycemia but also related to chronic complications and comorbidities of diabetes. Box 7023 https://doi.org/10.2337/dc21-S014. Type 2 diabetes is often associated with obesity. Topics covered are of interest to clinically oriented physicians, researchers, epidemiologists, psychologists, diabetes care and education specialists and other health care professionals. 3/6/18, 3/12/2019, 3/9/2021. In light of the immediate nutritional and immunological benefits of breastfeeding for the baby, all women, including those with diabetes, should be supported in attempts to breastfeed. See Table 15.1 for additional details on elements of preconception care (17,19). PDF ACOG PRACTICE BULLETIN - SCL Health There are no intervention trials in offspring of mothers with GDM. B, 14.24 Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). A blood sugar level of 190 milligrams per deciliter (mg/dL), or 10.6 millimoles per liter (mmol/L), indicates gestational diabetes. Insulin resistance drops rapidly with delivery of the placenta. Insulin is the first-line agent recommended for treatment of GDM in the U.S. American Diabetes Association. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. Clinical trials have not evaluated the risks and benefits of achieving these targets, and treatment goals should account for the risk of maternal hypoglycemia in setting an individualized target of <6% (42 mmol/mol) to <7% (53 mmol/mol). A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. Medical Optimization of Management of Type 2 Diabetes Complicating Pregnancy (MOMPOD). Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable delivery strategies, and neither has been shown to be superior to the other during pregnancy (84). B, 14.26 Women with a history of gestational diabetes mellitus should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. C. Pregnancy in women with normal glucose metabolism is characterized by fasting levels of blood glucose that are lower than in the nonpregnant state due to insulin-independent glucose uptake by the fetus and placenta and by mild postprandial hyperglycemia and carbohydrate intolerance as a result of diabetogenic placental hormones. E, 15.21 Potentially harmful medications in pregnancy (i.e., ACE inhibitors, angiotensin receptor blockers, statins) should be stopped at conception and avoided in sexually active women of childbearing age who are not using reliable contraception. A cost-benefit analysis has concluded that this approach would reduce morbidity, save lives, and lower health care costs (112). Of women with a history of GDM and prediabetes, only 56 women need to be treated with either intervention to prevent one case of diabetes over 3 years (111). Standard care includes screening for sexually transmitted diseases and thyroid disease, recommended vaccinations, routine genetic screening, a careful review of all prescription and nonprescription medications and supplements used, and a review of travel history and plans with special attention to areas known to have Zika virus, as outlined by ACOG. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes2022. Concentrations of glyburide in umbilical cord plasma are approximately 5070% of maternal levels (63,64). Diabetes Care 1 January 2021; 44 (Supplement_1): S200S210. The food plan should provide adequate calorie intake to promote fetal/neonatal and maternal health, achieve glycemic goals, and promote weight gain according to 2009 Institute of Medicine recommendations (62). However, in women with diabetes, hyperglycemia occurs if treatment is not adjusted appropriately. The A1C target in a given patient should be achieved without hypoglycemia, which, in addition to the usual adverse sequelae, may increase the risk of low birth weight (46). Diabetes | American Dental Association The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). In a pregnancy complicated by diabetes and chronic hypertension, a target goal blood pressure of 110135/85 mmHg is suggested to reduce the risk of uncontrolled maternal hypertension and minimize impaired fetal growth (114116). . Several studies have shown improved diabetes and pregnancy outcomes when care has been delivered from preconception through pregnancy by a multidisciplinary group focused on improved glycemic control (2528). None of the currently available human insulin preparations have been demonstrated to cross the placenta (8489). In women with normal pancreatic function, insulin production is sufficient to meet the challenge of this physiological insulin resistance and to maintain normal glucose levels. There are no data to support the use of TIR in women with type 2 diabetes or GDM. 14.14 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. Both metformin and intensive lifestyle intervention prevent or delay progression to diabetes in women with prediabetes and a history of GDM. Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (120). However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. The most important diabetes-specific component of preconception care is the attainment of glycemic goals prior to conception. See PREGNANCY AND ANTIHYPERTENSIVE MEDICATIONS in Section 10 Cardiovascular Disease and Risk Management (https://doi.org/10.2337/dc21-S010) for more information on managing blood pressure in pregnancy. This difference was not found in the Adelaide cohort. Long-term safety data for offspring exposed to glyburide are not available (66). As a world leader in diabetes care, the ADA is proud to set the standards!, said Boris Draznin, MD, PhD, Chair of the Professional Practice Committee. Preprandial testing is also recommended when using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted. B, 15.9 When used in addition to pre- and postprandial blood glucose monitoring, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy. A. GDM is characterized by increased risk of large-for-gestational-age birth weight and neonatal and pregnancy complications and an increased risk of long-term maternal type 2 diabetes and offspring abnormal glucose metabolism in childhood. Depending on the population, studies suggest that 7085% of women diagnosed with GDM under Carpenter-Coustan criteria can control GDM with lifestyle modification alone; it is anticipated that this proportion will be even higher if the lower International Association of the Diabetes and Pregnancy Study Groups (59) diagnostic thresholds are used. The objective of the Joslin Guideline for Detection and Management of Diabetes in Pregnancy is to support clinical practice and to influence clinical behaviors in order to improve clinical outcomes and assure that patient expecta- tions are reasonable and informed. Complications of gestational diabetes. Use of the CGM-reported mean glucose is superior to the use of estimated A1C, glucose management indicator, and other calculations to estimate A1C given the changes to A1C that occur in pregnancy (49). A review of current evidence, 2020 by the American Diabetes Association, Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (108). Of women with a history of GDM and prediabetes, only 56 women need to be treated with either intervention to prevent one case of diabetes over 3 years (123). Effective preconception counseling could avert substantial health and associated cost burdens in offspring (9). E, 15.6 Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Merrifield, VA 22116-7023. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. The DRI for all pregnant women recommends a minimum of 175 g of carbohydrate, a minimum of 71 g of protein, and 28 g of fiber. If the pregnancy has motivated the adoption of a healthier diet, building on these gains to support weight loss is recommended in the postpartum period. Medical nutrition therapy for GDM is an individualized nutrition plan developed between the woman and an RD/RDN familiar with the management of GDM (56,57). Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. 14.16 Insulin should be used for management of type 1 diabetes in pregnancy. Education for patients and family members about the prevention, recognition, and treatment of hypoglycemia is important before, during, and after pregnancy to help to prevent and manage the risks of hypoglycemia.

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